Prognostic factors and long-term outcomes following a modified Thompson’s quadricepsplasty for severely stiff knees

4-in-1 Quadricepsplasty for Habitual and Fixed Lateral Patellar Dislocation in Children

BACKGROUND

Habitual and fixed patellar dislocations represent extreme forms of patellar instability and can lead to significant functional loss. The underlying complex pathoanatomy of a laterally positioned and shortened extensor mechanism poses challenges in its management. The purpose of our study was to evaluate the anatomic risk factors and outcomes of a 4-in-1 quadricepsplasty (wide lateral releases, Insall proximal tube realignment, Roux-Goldthwait patellar tendon hemi-transfer, and step-wise quadriceps lengthening) for stabilization of habitual and fixed patellar dislocation.

METHODS

In a retrospective study, all patients with habitual and fixed patellar dislocation who underwent 4-in-1 quadricepsplasty and had a minimum 2-year follow-up were identified. Preoperative magnetic resonance imagings were evaluated for the presence of anatomic risk factors. As a prospective part of the study, patient-reported outcomes were collected using validated instruments including Pedi-IKDC, HSS-Pedi FABS activity score, BPII 2.0 score, Kujala score, and KOOS score.

RESULTS

Seventeen knees (12 patients) formed the study cohort. Twelve knees had habitual dislocation (9 in extension and 4 in flexion) and 5 had fixed dislocation. Mean age was 9 years. 6/17 (35.3%) knees were associated with syndromes. On magnetic resonance imaging, trochlear dysplasia was the most common anatomic risk factor present in 15/17 (88.2%) knees. 13/17 (76%) knees had presence of 2 or more risk factors. At the mean follow-up of 43.3 months, the mean Pedi-IKDC score was 88.1, the HSS-Pedi FABS activity score was 15.6, the BPII 2.0 score was 78.2, the Kujala score was 90, KOOS score was 93.9, and overall patient satisfaction score was 83.3. For complications, 3/17 knees (17.6%) had recurrent patellar instability, 1 knee had postoperative stiffness that required manipulation under anesthesia and 1 knee had a superficial wound infection.

CONCLUSIONS

Most patients with habitual and fixed patellar dislocation present during the first decade of life. There are several underlying anatomic risk factors, the most common being trochlear dysplasia and patellar tilt. The 4-in-1 quadricepsplasty technique provides reliable patellar stabilization, satisfactory clinical results, and acceptable patient-reported outcomes at a minimum 2-year follow-up, with a 17.6% redislocation rate.

LEVEL OF EVIDENCE

Level IV.

Modified Judet's quadricepsplasty plus patellar traction for knee stiffness after femoral fracture surgery

BACKGROUND

To investigate the clinical effect of modified Judet quadricepsplasty (MJ) combined with patella traction designed by ourselves in the treatment of knee joint rigidity after a femoral fracture.

METHODS

We retrospectively reviewed the clinical data of 21 patients with stiff knee joint after a femoral fracture treated by modified Judet quadricepsplasty combined with patella traction designed by the author from May 2014 to January 2017. The age at revision surgery was 20-57 (36 ± 12) years. The time between fracture fixation to quadricepsplasty was five to 23 (15 ± 5) months, and the follow-up was 11-32 (18 ± 6) months. Pre-operative, intra-operative, post-operative and final follow-up range of motion (ROM), the total traction time, and complications were assessed. The knee joint function was evaluated according to Judet's classification scheme.

RESULTS

Knee ROM was 5-60 (36 ± 13) ° pre-operatively, and 30-80 (53 ± 13) ° after MJ (an increase of 0-30 (17 ± 10)) (p < 0.05). The duration of patellar traction was ten to 14 (11 ± 2) days. Knee ROM after traction device removal was 90-100 (92 ± 3) °, an increase of 10-65 (39-14) ° compared with the ROM after arthrolysis (p < 0.05). The follow-up duration was 11-32 (18 ± 6) months. Knee ROM at final follow-up was 80-130 (104 ± 12) °, an increase of 40-100 (68 ± 16) 8° compared with pre-operatively (p < 0.05), and of - 10-40 (12 ± 13) ° compared with the ROM after traction removal (p < 0.05). Knee function was excellent in 14 cases (67%), good in 6 (28%), and fair in one (5%).

CONCLUSIONS

The MJ plus patellar traction lengthens the contracted quadriceps femoris, thus restoring knee function within a short period of time.

All-arthroscopic release for treating severe knee extension contractures could improve the knee range of motion and the mid-term functional outcomes

PURPOSE

To evaluate the safety, feasibility, and effectiveness of an all-arthroscopic technique for the intra- and extraarticular release of severe knee extension contractures.

METHODS

From 2012 to 2016, 25 patients with severe knee extension contractures (less than 45° range of flexion) were treated with an all-arthroscopic release technique. The patients underwent intra- and extraarticular arthroscopic release and arthroscopic-assisted mini-incision quadriceps plasty. The post-operative rehabilitation was initiated the first day after the procedures. Comprehensive clinical follow-up evaluations including the range-of-motion (ROM) assessment, the Lysholm score, and the International Knee Documentation Committee (IKDC) score were performed on all patients.

RESULTS

The median follow-up time was 28 months (range 12-65 months). The ROM improved from 23.9° ± 7.5° pre-operatively to 105.9° ± 6.5° at the final follow-up (P < 0.001). In addition, the Lysholm score increased from 59.9 ± 5.2 pre-operatively to 89.7 ± 3.3 (P < 0.001). The IKDC score increased from 47.6 ± 3.4 pre-operatively to 91.7 ± 2.4 (P < 0.001). All patients were satisfied with their final ROM and functional outcomes.

CONCLUSION

The all-arthroscopic release technique was a safe, feasible and effective method for treating severe knee extension contractures. The severe knee extension contractures may be successfully addressed by the all-arthroscopic release technique during our clinical practice.

LEVEL OF EVIDENCE

IV.

The Anatomy of the Articularis Genus Muscle and Its Relation to the Extensor Apparatus of the Knee

Background:

The anatomy of the articularis genus muscle has prompted speculation that it elevates the suprapatellar bursa during extension of the knee joint. However, its architectural parameters indicate that this muscle is not capable of generating enough force to fulfill this function. The purpose of the present study was to investigate the anatomy of the articularis genus, with special emphasis on its relationship with the adjacent vastus intermedius and vastus medialis muscles.

Methods:

The articularis genus muscle was investigated in 18 human cadaveric lower limbs with use of macrodissection techniques. All components of the quadriceps muscle group were traced from origin to insertion, and their affiliations were determined. Six limbs were cut transversely in the middle third of the thigh. The modes of origin and insertion of the articularis genus, its nerve supply, and its connections with the vastus intermedius and vastus medialis were studied.

Results:

The muscle bundles of the articularis genus were organized into 3 main layers: superficial, intermediate, and deep. The bundles of the superficial layer and, in 60% of the specimens, the bundles of the intermediate layer originated from both the vastus intermedius and the anterior and anterolateral surfaces of the femur. The bundles of the deep layer and, in 40% of the specimens, the bundles of the intermediate layer arose solely from the anterior surface of the femur. The distal insertion sites included different levels of the suprapatellar bursa and the joint capsule. A number of connections between the articularis genus and the vastus intermedius were found. While the vastus medialis inserted into the whole length of the vastus intermedius aponeurosis, it included muscle fibers of the articularis genus, building an intricate muscle system supplied by nerve branches of the same medial deep division of the femoral nerve.

Conclusions:

The articularis genus, vastus medialis, and vastus intermedius have a complex, interacting architecture, suggesting that the articularis genus most likely does not act as an independent muscle. With support of the vastus intermedius and vastus medialis, the articularis genus might be able to function as a retractor of the suprapatellar bursa. The finding of likely interplay between the articularis genus, vastus intermedius, and vastus medialis is supported by their concurrent innervation.

Clinical Relevance:

The association between the articularis genus, vastus medialis, and vastus intermedius may be more complex than previously believed, and this close anatomical connection could have functional implications for knee surgery. Dysfunction, scarring, or postoperative arthrofibrosis of the sophisticated interactive mechanism needs further investigation.

Outcome of Judet's quadricepsplasty for knee contractures and the effect of local infiltration of epinephrine on reducing blood loss

OBJECTIVE

To evaluate the effectiveness of Judet's quadricepsplasty for treatment of knee contractures and to identify the effect of local infiltration of epinephrine on blood loss associated with this procedure.

METHODS

A retrospective cohort study was conducted in which all cases of knee contractures managed with Judet's quadricepsplasty from 1st January 2009 to 31st December 2013 were included and were divided into two groups. The epinephrine group included patients who were infiltrated with diluted epinephrine (1:400,000) along with xylocaine, around the operative field 15 min prior to the incision time, while the control group did not receive any infiltration. Judet's outcome, blood loss, drop in hemoglobin and required blood transfusion were noted for all patients and compared between both groups.

RESULTS

Most common preceding pathology identified for the development of knee contractures was periarticular fracture while ilizarov application was the most common etiology. Both groups were found similar in all preoperative characteristics except preoperative flexion contracture (p = 0.02). All functional outcome measures including Judet's outcome were similar in both groups. In contrast, duration of surgery (p = 0.01), blood loss (p = 0.02), drop in hemoglobin (p = 0.01) and number of transfusions (p = 0.03) were significantly reduced in epinephrine group.

CONCLUSION

Judet's quadricepsplasty is a useful procedure to increase the range of motion of rigid knees and local infiltration of epinephrine is effective in decreasing the amount of subsequent blood loss and transfusion requirements.

Manipulation under anesthesia for post traumatic stiff knee-pearls, pitfalls and risk factors for failure

BACKGROUND

Stiffness is common following fractures around knee. Manipulation under anesthesia (MUA) is the initial noninvasive procedure usually performed for such patients. Though MUA has been extensively evaluated for knee arthroplasty, there is paucity of literature regarding its benefits in trauma cases. The purpose of this study was to define the role of manipulation in post traumatic stiff knees.

METHODS

Hospital inpatient and outpatient records from January 2010 to June 2014 were retrospectively reviewed to identify patients undergoing MUA at our institution. Patients with more than one year follow up and adequate data were included. Clinical and radiographic parameters were analyzed to assess outcomes, complications, effect of timing on flexion gain as well as identify risk factors associated with failure.

RESULTS

Out of 45 patients undergoing manipulation, 41 patients with 48 knees (34 unilateral and 7 bilateral) met inclusion criteria. Thirty six manipulations were successful while 3 were abandoned due to tight tissues and 9 developed complications.Successful MUA resulted in immediate gain of 62.36° of flexion which decreased to 49.86° at 1year. There was statistically significant loss of flexion of 12.5° over a year (p value 0.0013). Arc of motion improved from 48.5° to 106.1° at 1year (p value <0.0001). Significant improvement was also seen in extension and fixed flexion deformity (p value <0.0001). No significant difference could be detected between early (<3 months) and late (>3 months) groups with respect to outcomes (p value 0.883)or complications (p value 0.3193). Failed group had significantly lower pre MUA flexion and pre MUA range of motion (p value 0.003). Univariate analysis showed that extensor mechanism ruptures during injury (p value <0.0001) and knees with Flexion <40° (p value 0.0022) or ROM<30° (p value 0.0002) were significantly associated with failures.

CONCLUSION

MUA is a suitable non invasive treatment option for post traumatic stiffness. There is no effect of timing on outcome and late manipulation also results in good outcome. Extensor mechanism rupture and pre manipulation ROM<30° or flexion <40° are associated with failure and such cases should be considered for alternative options for better outcome.

A mini-invasive technique for severe arthrofibrosis of the knee: A technical note

PURPOSE

In this article, a mini-invasive technique is described, which consists of arthroscopic adhesiolysis and quadriceps pie-crusting lengthening basing on pre-operative sonographic examination. Sonographic diagnostic value of quadriceps tendon fibrosis is also evaluated.

METHODS

Pre-operative sonographic examination was performed to make an accurate location diagnosis of quadriceps fibrosis. After arthroscopic adhesiolysis, percutaneous pie-crusting release was performed basing on preoperative sonographic examination. An 18-gauge needle was used to puncture the stiff fibrous band of the distal and lateral quadriceps tendon under maximum knee flexion. The contractural quadriceps tendon is gradually released after 60-100 needle punctures.

RESULTS

This technique was performed in five post-traumatic stiff knees and three stiff knees after previous infection. The contractural rectus femoris tendon is average 22% thinner than contralateral parts according to sonographic measurement. Mean maximum flexion increased from 35° preoperatively to 80° after arthroscopic adhesiolysis and 120° after pie-crusting.

CONCLUSIONS

This technique is a simple, effective and mini-invasive method, allowing an immediate, aggressive rehabilitation postoperatively. Pre-operative sonographic location of quadriceps tendon fibrosis could potentially improve the efficacy and accuracy of percutaneous pie-crusting procedures.

Retrograde locked intramedullary nailing for aseptic supracondylar femoral nonunion following failed locked plating

PURPOSE

To review the outcome of retrograde locked nailing for aseptic supracondylar femoral nonunions following failed locked plating.

METHODS

Records of 20 men and 4 women aged 20 to 57 (mean, 39) years who underwent retrograde locked intramedullary nailing for aseptic supracondylar femoral nonunion following failed locked plating were reviewed. There were 20 closed and 4 open Gustilo type II or IIIA fractures secondary to motor vehicle accidents (n=21) or falls (n=3). Patients had undergone one to 3 operations. The mean time from injury to the present revision surgery was 1.3 years. No patient had a flexion contracture. The locked plate was removed and replaced with a retrograde dynamic locked nail (with or without buttress plate augmentation) followed by bone grafting.

RESULTS

17 men and 4 women were followed up for a mean of 3.4 years. The rest were lost to follow-up. The 21 patients achieved bone union after a mean of 4.3 months. The mean maximal knee flexion improved from 97.1º to 107.6º (p=0.03). Knee function was excellent in one, good in 15, and fair in 5 knees. The fair outcome was due to extension contracture, varus knee deformity, or knee pain. There were 3 malunions with varus deformity of 7º, 8º, and 9º each. No patient had deep infection causing a nonunion. All 21 patients could walk without aids.

CONCLUSION

Retrograde locked intramedullary nailing for aseptic supracondylar femoral nonunions following failed locked plating achieved a high union rate.

[Treatment of extension contracture of the knee by quadriceps plasty (Judet procedure)]

OBJECTIVE

Knee flexion is increased by detachment of contracted quadriceps muscle from the pelvis and femur in combination with arthrolysis of the knee.

INDICATIONS

Flexion contracture of the knee caused by extraarticular changes of quadriceps muscle (fibrosis, soft-tissue damage, infection, fracture). Failed intraarticular arthrolysis. Intraarticular treatment insufficient.

CONTRAINDICATIONS

Isolated intraarticular fibrosis of the knee. Infection of the knee or the soft tissues. Soft tissue defects in the area of the incision. Noncompliance of patient. Neurologic reasons for flexion contracture.

SURGICAL TECHNIQUE

Medial arthrotomy. Arthrolysis and resection of adhesions in the superior recess and lateral gutters. Incision of retinaculae preparing a lengthening. The vastus medialis muscle is dissected from the intermuscular septum from distal to proximal. The proximal third of the muscle is spared. The incision is now extended proximally and laterally. The vastus lateralis muscle is released from the intermuscular septum from distal to proximal. The insertion of vastus lateralis muscle is detached at the proximal femur. The conjoint tendons of rectus femoris muscle are released at the anterior inferior iliac spine. The knee is gradually flexed, residual adhesions are addressed. The proximal part of the vastus medialis has to be preserved since it covers the neurovascular supply of the quadriceps muscle. The knee is closed in flexion. The retinaculae are adapted as far as possible. Soft tissues and skin are closed in layers.

POSTOPERATIVE MANAGEMENT

The patient in placed on a continuous passive motion device for 7 days under peridural anesthesia. Partial weight bearing with crutches is advised for 6 weeks, quadriceps training is started early to treat the active extension deficit.

RESULTS

Our results reveal that operative treatment of complex flexion deficits lead to objective and subjective improvements. After 8.2 months, 17 of 19 patients had a mean gain of flexion of 26°. Subjectively 10 patients were highly satisfied and 7 were satisfied after operative treatment.

Percutaneous quadriceps tendon pie-crusting release of extension contracture of the knee

To release extension contracture of the knee, the authors used a minimally invasive technique: percutaneous quadriceps tendon pie-crusting release. Percutaneous pie-crusting release was performed using an 18-gauge needle to puncture the stiff fibrous band of the distal and lateral quadriceps tendon under maximum knee flexion. Quadriceps contracture was gradually released by multiple needle punctures. A knee brace was prescribed for one week and knee flexion exercises were performed on the first postoperative day. This technique was performed in seven post-traumatic stiff knees and five stiff total knee arthroplasties. Mean maximum flexion increased from 37° preoperatively to 50° after arthrolysis and 107(o) after pie-crusting. At a mean follow-up of eight months, mean maximum flexion was 103°. There were no major complications. The technique of quadriceps tendon pie-crusting release is a simple, minimally invasive and effective treatment for knee extension contracture.

Treatment of femoral lengthening-related knee stiffness with a novel quadricepsplasty

BACKGROUND

Knee stiffness is common after femoral lengthening. Certain patients require a quadricepsplasty when therapy does not improve flexion. A small subset of such patients may also have obligate patellar dislocation with knee flexion due to contracture of the extensor mechanism. We describe our surgical approach for both clinical situations and our outcomes in a pediatric population.

METHODS

Six patients, 2 with obligate patellar dislocation, were reviewed (9% of our femoral lengthening population). Indications for surgery included persistent symptomatic restriction of flexion after at least 3 months of therapy or obligate lateral patellar dislocation with knee flexion. Knee range of motion and clinical strength were assessed. Four patients were available for gait analysis and concentric quadriceps strength testing by isokinetic dynamometer. Patient satisfaction was surveyed by questionnaire.

RESULTS

All patients had full flexion before lengthening. The mean length gained (by circular external fixation and/or intramedullary motorized nail) was 10.7 cm. The mean age at the time of quadricepsplasty was 16 years. The average active flexion preoperatively was only 48 degrees. Two patients with obligate patellar dislocation and relatively good knee flexion inflated the average preoperative knee flexion. Although both had knee flexion to 100 degrees, the patella dislocated with flexion beyond 30 degrees. At follow-up (mean, 6.2 y) active flexion averaged 120 degrees (P<0.004). All patients had 5/5 clinical strength and no significant quadriceps lag. No patients had patellar instability postoperatively. Isokinetic dynamometer revealed an average weakness of 63% compared with the nonoperative quadriceps. Gait analysis indicated patients had near-normal gait patterns. All patients were satisfied and would pursue the same treatment.

CONCLUSIONS

Our quadricepsplasty can significantly increase knee flexion and treat obligate patellar dislocation in the setting of extension contracture after femoral lengthening when nonoperative measures fail.

LEVEL OF EVIDENCE

Level IV.

Predictive factors for knee stiffness after periarticular fracture: a case-control study

BACKGROUND

Knee stiffness is an important complication after periarticular fracture, but a systematic evaluation of risk factors for this complication and outcomes of treatment has not been undertaken, to our knowledge. The aims of this study were to evaluate risk factors for knee stiffness requiring manipulation after periarticular fracture and to document the clinical outcomes of the manipulation.

METHODS

This study was designed as a case-control study in which patients requiring manipulation under anesthesia after periarticular fracture were compared with those who did not require manipulation. Using billing data from a regional level-I trauma center, we identified twenty-four knees requiring manipulation for refractory stiffness over a six-year period. These were matched, on the basis of the AO/OTA classification, with forty-three control knees that did not develop stiffness requiring manipulation. Descriptive statistics were used for frequency and mean analysis.

RESULTS

Univariate analysis revealed that extensor mechanism disruption (chi square = 0.05), fasciotomy (chi square = 0.020), wounds requiring ongoing management and precluding knee motion (p = 0.001), and the need for more than two surgical procedures to achieve definitive fracture fixation and soft-tissue coverage (p = 0.003) all placed patients at increased risk for knee stiffness requiring manipulation. The mean improvement in knee motion following all procedures targeting knee stiffness was 62°. Mean final flexion was significantly less in the case group (107°) compared with the control group (124°; p=0.01).

CONCLUSIONS

To our knowledge, this is the first study to systematically evaluate the risk factors for knee stiffness after periarticular fracture and document the outcomes of manipulation under anesthesia. It demonstrates that injury characteristics that delay or prevent postoperative knee motion place patients at increased risk for refractory knee stiffness. Although knee motion remains compromised, late surgery aimed at improving knee motion leads to improvements in flexion

Treating stiffness after total knee arthroplasty: a technical note and preliminary results

Total Knee Replacement is used to treat pain, stiffness and reduced range of movement. It has been estimated that a minimum of 90 degrees of range of motion in the knee is required for normal activities of daily living. In this article we demonstrate a technical note with a small patient series about the methods of treating knee stiffness after Total Knee Replacement.

Judet quadricepsplasty in the treatment of posttraumatic knee rigidity: long-term outcomes of 45 cases

BACKGROUND

Posttraumatic knee stiffness is a very debilitating condition. Judet's quadricepsplasty technique has been used for more than 50 years. However, few reports of quadricepsplasty results exist in the literature.

METHODS

We report the results of 45 cases of posttraumatic arthrofibrosis of the knee treated with Judet's quadricepsplasty. The results of the procedure were analyzed by measuring the degrees of flexion of the operated knees at different time points (before, immediately after, and late postoperatively).

RESULTS

The degree of flexion increased from 33.6 degrees (range, 5–80 degrees) preoperatively to 105 degrees (range, 45–160 degrees)immediately after surgery, followed by a slight fall in the range of motion (ROM) in the late postoperative period, which reached an average of 84.8 degrees. There was no significant correlation between knee strength and the patient's gender, but there was a slight trend of lower strength with age. Although Judet's quadricepsplasty technique dates from more than 50 years ago, it still provides good outcomes in the treatment of rigid knees of various etiologies. In general, all cases showed the same pattern of a small decrease in the ROM in the late postoperative period.

CONCLUSION

Judet's quadricepsplasty can increase the ROM of rigid knees. The ROM obtained with the surgery persists long term.